WELCOME TO AGEWELL MEDICAL ASSOCIATES
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1 WELCOME TO AGEWELL MEDICAL ASSOCIATES We offer the following checklist and suggestions to help make your first visit as easy and pleasant as possible. What to bring with you: [ ] All of your medications in their bottles (prescription and non-prescription, including vitamins). [ ] Health History form (fill it out ahead of time). To include: List of drug allergies and/or drug sensitivities. 2 emergency contact names and phone numbers (1 may be your spouse) [ ] Geriatric Depression Screen (fill it out ahead of time). [ ] Copies of your Living Will and/or Durable Power of Attorney for Health Care, if you have them. [ ] Current insurance cards (including prescription drug coverage). We need to make copies for your chart in order to bill the carriers for your office visits. What to expect at your Comprehensive Geriatric Assessment Visits: (please allow up to 2 hours for your first time visit.) Establish your medical care with your primary care provider Limited physical exam Review of your current medications Review of your medical and surgical history Review and discuss your advanced directives (Living Will, Medical Durable POA, etc.) Review and discuss preventive care Written instructions for changes in treatment plans, lab orders, or diagnostic studies Please be here 30 minutes prior to your scheduled appointment time. Your appointment is on, the of at_ Your primary care provider will be:.if you have any questions, please call us at (719) Our hours are 8:00 AM to 4:30 PM weekdays. IF YOU ARE UNABLE TO KEEP YOUR APPOINTMENT, PLEASE CALL US AS SOON AS POSSIBLE TO RESCHEDULE. THANK YOU. (1)
2 FOR OFFICE USE ONLY: MEDICARE OR OTHER NO AD LW / MDPOA SENIOR HEALTH HISTORY NAME: First MI Last TELEPHONE NUMBER: BIRTHDATE: PHYSICAL ADDRESS: Street City Zip Code BILLING ADDRESS: (If different Street City Zip Code from above) SSN: MARITAL STATUS: Married Single Divorced/Separated Widowed CURRENT LIVING ARRANGEMENTS (i.e. own home, assisted living, etc): EMERGENCY CONTACT NUMBERS: Name: Relationship: Phone: Cell: Name: Relationship: Phone: Cell: Medical Power of Attorney: Phone: PHARMACY: DURABLE MEDICAL EQUIPMENT SUPPLIER: Transportation Contact: (2)
3 AGEWELL MEDICAL ASSOCIATES SENIOR HEALTH HISTORY Race: American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Prefer not to give Ethnicity: Hispanic or Latino Not Hispanic or Latino Prefer not to give Primary Language: (Choose 1) English French German Japanese Mandarin Russian Spanish Name: (3)
4 MEDICAL / SURGICAL/ HOSPITALIZATION HISTORY HAVE YOU BEEN TOLD THAT YOU HAVE DIABETES OR ELEVATED BLOOD SUGAR? Y N If you answered YES to the question above, please answer questions 1 through 4 1. DATE OF LAST A1C TEST (IF KNOWN): 2. RESULT OF LAST A1C: 3. DATE OF LAST DIABETIC EYE EXAM: 4. WHERE DONE? DO YOU CHECK YOUR BLOOD SUGARS? Y N How often? MAJOR MEDICAL PROBLEMS: PAST SURGERIES (INCLUDE DATES/YEAR) HOSPITALIZATIONS FOR SERIOUS ILLNESS: Name: (4)
5 NAMES OF OTHER PROVIDERS INVOLVED IN YOUR CARE NAME SPECIALTY HAVE ANY OF YOUR CLOSE RELATIVES HAD ANY HEALTH CHANGES? YES / NO (PARENTS, SIBLINGS, CHILDREN) IF YES PLEASE LIST BELOW: DO YOU OR HAVE YOU EVER USED: TOBACCO Y/ N IF YES, THEN HOW MUCH DID YOU USE AND FOR HOW LONG? YEAR QUIT ALCOHOL Y / N IF YES, HOW MUCH DO YOU DRINK AND HOW OFTEN? ARE YOU WORRIED ABOUT OR HAVE YOU HAD A RECENT FALL? Y / N ARE YOU WORRIED ABOUT YOUR MEMORY? Y / N Name: (5)
6 PLEASE CHECK ANY PREVENTIVE TESTING YOU HAVE HAD DONE TEST DATE OF TESTING FACILITY MAMMOGRAM COLONOSCOPY BONE DENSITY PAP/PELVIC EXAM PROSTATE EXAM EYE EXAM DENTAL EXAM PROSTATE BLOOD TEST THYROID BLOOD TEST CHOLESTEROL BLOOD TEST HAVE YOU HAD ANY IMMUNIZATIONS? VACCINE YES / NO DATE INFLUENZA (FLU) PNEUMOVAX (PNEUMONIA) ZOSTAVAX (SHINGLES) TETANUS DO YOU USE OXYGEN? YES / NO DO YOU USE CONTINUOUS (24 HOURS)? YES / NO DO YOU USE AT NIGHT ONLY? YES / NO BY NASAL TUBING? YES / NO BY MASK? YES / NO CPAP / BIPAP (CIRCLE ONE) WHAT OXYGEN COMPANY DO YOU USE? _ DO YOU HAVE A LIVING WILL OR ADVANCED DIRECTIVE? YES / NO (IF YOU HAVE ONE, PLEASE BRING IT TO THE VISIT) Name: (6)
7 MEDICATION HISTORY ARE YOU ALLERGIC TO ANY MEDICATIONS AND IF SO PLEASE LIST THEM WITH THE REACTION YOU HAD BELOW MEDICATION ALLERGY REACTION NEW PATIENTS ONLY: PLEASE BRING ALL YOUR CURRENT PRESCRIPTION MEDICATIONS, OVER THE COUNTER MEDICATION, VITAMINS AND ANY SUPPLEMENTS YOU ARE TAKING. Name: (7)
8 PHQ-4 Over the last 2 weeks, how often have you been bothered by the following problems? (Circle answer in each column) Not Several More than Nearly at all days half the every day days Little interest or pleasure in doing things Feeling down, depressed, or hopeless Feeling nervous, anxious or on edge Not being able to stop or control worrying Name: (8)
WELCOME TO AGEWELL MEDICAL ASSOCIATES
WELCOME TO AGEWELL MEDICAL ASSOCIATES We offer the following checklist and suggestions to help make your first visit as easy and pleasant as possible. What to bring with you: [ ] All of your medications
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Please complete and return to the office prior to your appointment.
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Adult Demographics Form
Adult Demographics Form Patient s Name: Preferred Name: Age: Patient s Social Security Number: Date of Birth: Sex: M / F Home Address: Apt: City: State: Zip: Cell phone #: Home Phone #: Work phone #: Email:
o Kidney Cancer o Liver Cancer o Tremor o Tuberculosis o B12 Deficiency o Esophageal Cancer o Liver Disease o Pituitary Tumor o Uterine o Neurological
Adult New Patient Registration PATIENT DOB: / / MONTH DAY YEAR PATIENT NAME: LAST FIRST MI o Abnormal Heartbeat Patient Medical History: Please mark all that apply o Chronic Headaches o Hepatitis C o Neuropathy
Participant Self-Assessment of Diabetes Management
Participant Self-Assessment of Diabetes Management Name: Date: Date of Birth: Age: Gender: F M Ethnic Background: White/Caucasian Black/African American Hispanic Native American-Alaska Asian/Pacific Islander
GoPrivateMD General Information & History
Date: Date of Birth: Age: Sex: Male Female Address: City: State: Zip: Telephone: Email: PREFFERED PHARMACY NAME & LOCATION: PRIMARY PHYSICIAN: SPECIALISTS: INSURANCE GoPrivateMD will not bill your insurance.